When a physician refers a patient to a specialist, such as a radiologist or oncologist, the referring physician writes a medical order providing instructions to the specialist. The order typically includes minimal information, usually formatted as unstructured text, commonly called a “history” or “question” that describes an ongoing problem, identifies a suspected medical problem, or poses a question to the specialist. For example, the ordering physician may suspect the patient has breast cancer and may ask in a written medical order that a radiologist attempt to rule out metastases. In another example, the patient may have a recent history of abdominal pain, and the referring physician may seek an opinion regarding whether the patient has an infection. In some cases, the written medical order will include instructions for the specialist to perform a particular study, though in other cases it is up to the specialist to review the written medical order and perform any studies useful in answering the physician's posed questions.
The specialist's studies may include X-ray images of the patient, quantitative laboratory results, such as blood lead level or standardized uptake values measured by positron emission tomography (PET), or the like. The specialist interprets the studies to confirm or refute the suspected medical problem or to answer the question posed in the order.
Background information about the patient and the patient's medical history can aid the specialist in interpreting the results of any performed studies. For example, knowing that the patient has a recent history of elevated white blood count may cause the specialist to consider a particular interpretation of a study to be more likely than if the patient had a normal white blood count.
In many cases, though, the specialist has no prior knowledge of the patient or the patient's medical history, and the medical order usually provides the specialist with little or no background information. As a result, the specialist is often required to interpret the study with only the information written in the medical order. Otherwise, the specialist is required to take additional time to access the patient's medical records and search for data that may be relevant to the question or study at hand.
These searches of a patient's longitudinal medical record (LMR) can be extremely time consuming. For example, in a radiological study, LMR searching can consume 20-53% of the total interpretation time of the study. Similar LMR searches may be performed in 27-64% of all Abdominal-Pelvic CT (ABP-CT), Transvaginal Pelvic Ultrasound (TV-US), and Brain MRI (B-MRI) studies. In a relatively large hospital, every week many hundreds of these studies may be performed. Therefore, a large amount of time and health care money is spent manually searching patient medical records for ancillary medical data.